April 17, 2015

Sidestepping the ICD-10 Operations Bottleneck on Oct. 1, 2015

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Now that the sustainable growth rate (SGR) bill has been signed by the president without any further ICD-10 delay language, it’s time to proceed with ICD-10. Although there are many speculations regarding increased data causing operational bottlenecks, it may not necessarily be due to a huge spike in claims volume on Oct. 1, 2015. Hospitals will not discharge more patients on Oct. 1 than they typically do, nor is an abnormally massive influx of claims transactions anticipated.

However, what will be new are the ICD-10-CM/PCS codes and the systems that have recently been upgraded or remediated to allow for receiving, sending, transmitting, and storing ICD-10 data. A number of factors should be taken into consideration to avoid or circumvent any potential bottlenecks on the provider side, as well as on the side of external trading partners, including payors and clearinghouses. Bottlenecks or glitches on either side will have a direct impact on the other, leading to a multi-factorial, interdependence risk. Provider and payor readiness and transparency are of the utmost importance in order to prevent operational bottlenecks. If ICD-10 testing cannot occur between a provider and its top payors, transparent communication regarding readiness and contingency plan instructions should be provided so that claims can be sent, received, acknowledged, and paid.

A recent conversation with Bryan Matsuura, executive director for ICD-10 implementation for all Kaiser Permanente institutions, validated a concern that was raised even during the ICD-10 national pilot program efforts in 2012. He stated that “we’re not as concerned about the potential internal glitches at Kaiser, since we can control and manage those. What we’re most concerned about are the issues that may arise on the side of the payors and our external trading partners – the things we can’t control or do anything about.”

Considerations in Preparing for ICD-10 Cutover

As a provider, there may not be much you can do about your external trading partners’ operational readiness. All you can do at this point is prepare to the best of your ability and deal with the bottlenecks if and when they occur. In the meantime, here are someconsiderations as you prepare for the cutover date:

  • Be proactive and anticipate delays: Since the majority of healthcare institutions may be processing ICD-10 data in production for the first time and may not have had ample time to test, be proactive and anticipate possible transmission, communication, acknowledgement, and payment delays. Brace for the impact, both financially and with people and resources.

  • Avoid the “big bang” approach: If possible, flip on the switch gradually in your enterprise. If you’re ready, begin going live one department at a time, starting now. Start off with dual coding, then work through the other departments in revenue cycle based on your readiness and priorities.

  • Consider staggering claims: If limited testing has been conducted by a hospital, consider purposely staggering claims and submitting the most accurate and complete claims first — those not likely to be rejected. In other words, figure out a way not to clutter the EDI traffic on the few days with submissions that may be missing some data (or perhaps those not having enough concrete, accurate information in the documentation).

  • Ensure that you can submit ICD-10 codes: On the implementation date, ensure that your entity has the ability to submit ICD-10 codes — this is going to be the most basic yet the most critical functionality requirement. If you’re not able to submit any type of claim using ICD-10 codes (electronic or paper), you will not be paid for your services.
    • Above all else, you must first be capable of submitting claims for services rendered (preferably electronically).
    • Once you’ve confirmed this capability, strive to submit clean claims without data errors by auditing your coders now for accuracy and by supporting them in their continued learning. Strive for a 95 percent coding accuracy rate or higher.
    • Keep in mind that the payors are not necessarily checking for your coding accuracy during the transition. Payors are leaving it up to the providers to ensure that their ICD-10-CM/PCS codes are complete, accurate, and a reflection of their clinical documentation.
    • Payors will be focused on paying the claims that have ICD-10 codes on them whether or not the claims contain all of the correct codes for diagnosis and procedures. This will be the responsibility of each coder and biller from each provider organization.
  • Support your coders: Ensure coder proficiency and provide refresher coder training before Oct. 1 if they were trained a long time ago. Consider assigning an expert and/or more senior coders that have had more extensive training and have been dual coding for some time to assist those less experienced coders.

  • Establish a strong command center with efficient processes and contingency plans:
    • The command center, supported by physician champions and health information management (HIM) department leads, must be diligent in managing coder query traffic. Ensure that physicians are responding to those queries quickly and efficiently while not making repeated mistakes.
    • The COO/operations team should be part of the command center, allowing the entity to anticipate, identify, and resolve operational bottlenecks. Develop contingency plans now that can be deployed immediately to solve issues.
    • The command center should be supported by an organized ICD-10 go-live team that will orchestrate everything that needs to happen on the cutover date. The go-live team should be empowered to foresee, identify, prioritize, and escalate issues quickly, and to propose solutions to the command center to avoid bottlenecks and negative financial impact.
  • Have at least six months of operating funds available: In the event of reimbursement bottleneck delays, the importance of having a minimum of six months’ worth of operating funds can’t be emphasized enough. This should be cash in the bank that can be accessed anytime or assets that can be liquidated in days (not weeks or months) should there be any delays in reimbursement.

Over-prepare for ICD-10 Success

Again, work to resolve and prevent your own internal bottlenecks by working on the solutions before challenges arise. Additionally, anticipate the issues your trading partners may face that could potentially impact your revenue, and strive to protect your enterprise from these impacts as much as possible. At the end of the day, all major conversions and changes will have repercussions – it’s what you do to prepare for them that counts. The ability to over-prepare for ICD-10 operational bottlenecks will determine your success in the end.

About the Author

Juliet Santos is the ICD-10 principal for Leidos Health. Santos was formerly the senior director for HIMSS Business Centered Systems and was the EVP for the Lott QA Group. She played key roles in the creation of the ICD-10 PlayBook, ICD-10 National Pilot Program, and the ICD-10 National Testing Platform.

Contact the Author

Contact the Editor      

                                     

Juliet A. Santos, MSN, CCRN, FNP-BC

Juliet Santos is the ICD-10 principal consultant for Leidos Health. Santos formerly was EVP of Lott QA Group and assisted with the creation of the ICD-10 PlayBook, ICD-10 National Pilot Program, and the ICD-10 National Testing Platform.

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